Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis

Change in willingness for surgery and risk of joint replacement after an education and exercise program for hip/knee osteoarthritis: A longitudinal cohort study of 55,059 people

BACKGROUND

Numerous studies report that education and exercise interventions can shift people's willingness to undergo joint replacement surgery for osteoarthritis. We aimed to investigate whether becoming unwilling to undergo surgery following an education and exercise intervention for hip and knee osteoarthritis is associated with lower probability of receiving actual surgery.

METHODS AND FINDINGS

This was a register-based cohort study including people from the Swedish Osteoarthritis Register who underwent a 3-month education and exercise intervention for knee or hip osteoarthritis. Participants self-reported their willingness to have joint replacement surgery ('yes' or 'no') and were grouped based on their response pre- and post-intervention (always willing for surgery; became unwilling for surgery; never willing for surgery; became willing for surgery). Data on joint replacement surgery was obtained through the Swedish Arthroplasty Register. The probability and hazard of surgery occurring, as well as the mean time without surgery was calculated up to 5-years (primary outcome) and 9-years (secondary outcome) post-intervention. We adjusted for age, sex, body mass index (BMI), education, joint pain, quality of life, walking difficulties, number of prior visits with an orthopedic surgeon, prior joint surgeries in the knee or hip (other than joint replacement), and comorbidities. 55,059 people were included, 69% were female (N = 37,739), with a mean age 66years (standard deviation [SD] = 9.3), and a BMI of 27.5 (SD = 4.9). In total, 70% (N = 38,386) were never willing for surgery, 14% (N = 7,736) were always willing for surgery, 10% (N = 5,649) became unwilling for surgery, and 6% (N = 3,288) became willing for surgery. Compared to those who were always willing for surgery, participants who became unwilling had a 20% (95% confidence interval [CI]: 18, 22%) lower probability of having surgery by 5-years post-intervention. This corresponded to delaying surgery by 1.1 (95% CI: 1.0, 1.1) years. Compared to those who were always willing for surgery, the hazard of surgery occurring at 1-year post-intervention was lower in those who became unwilling (hazard ratio (HR) 0.5 [95% CI: 0.4, 0.5]), though was then higher at 5-years (HR 1.4 [95% CI: 1.2, 1.7]). Estimates remained stable from 5 to 9 years. Limitations of our study include the inability to account for all potential confounders, and to infer the contribution of the intervention to change in willingness for surgery due to the absence of a control group. Data were collected in Sweden, generalisability to other countries may be limited.

CONCLUSIONS

Becoming unwilling for joint replacement surgery following an education and exercise program for hip and knee osteoarthritis could reduce the number of joint replacement surgeries by 20% at 5 years post-intervention, with the possibility of maintaining most of this reduction up to 9 years post-intervention. Interventions that can shift willingness to undergo surgery may thus result in relevant delays and reductions in future joint replacements.

Exercise interventions for treating work-related complaints of the arm, neck or shoulder in adults

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of exercise interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults. The outcomes of interest are pain, function, work outcomes, adverse events, quality of life, healthcare use and injury recurrence.

Comparative Efficacy of Supervised, Web-Based, and Self-Guided Exercise Interventions in Women with Patellofemoral Pain Syndrome

Background/Objectives: Patellofemoral pain syndrome (PFPS) is a common musculoskeletal condition that causes anterior knee pain, often linked to increased joint stress. Rehabilitation typically includes education, strength training, and functional exercises. Recently, telerehabilitation has become a promising alternative, particularly useful in improving access to care in rural areas. This study compares the effects of supervised (SE), web-based (WBE), and self-guided (SGE) exercise programs on pain, functionality, and fear of movement (kinesiophobia) in individuals with PFPS. Materials and Methods: Sixty female patients with PFPS participated in this randomized controlled trial. They were randomly assigned to one of three groups: SE, WBE, or SGE. Each program lasted six weeks, with exercises adjusted based on individual tolerance. Outcomes were assessed using the Kujala Anterior Knee Pain Scale, the visual analog scale (VAS) for pain, the Timed Up and Go Test (TUG) for mobility, and the Tampa Kinesiophobia Scale. Results: All groups showed significant improvements in pain, functionality, and kinesiophobia (p < 0.05). The SE group achieved the greatest improvements across all measures, reducing pain and kinesiophobia while enhancing functionality (p < 0.017). The WBE group also showed significant improvements, outperforming the SGE group in all outcomes (p < 0.017). The SGE group demonstrated the least improvement but still achieved positive changes. Conclusions: Supervised exercise programs were the most effective in managing PFPS symptoms. However, the web-based programs also provided substantial benefits, making them a viable option when in-person supervision is not feasible. Future research should aim to enhance digital interventions for broader accessibility and engagement. Trial Registration: The study protocol was also registered on ClinicalTrials.gov (NCT06625086).

Enhancing physiotherapists' knowledge and skills in facilitating self-management of patients with chronic musculoskeletal pain conditions: a best practice implementation project

INTRODUCTION

Evidence-based self-management strategies in chronic disease management are associated with increased self-efficacy and improved health-related quality of life. Physiotherapists feel unprepared to promote these strategies in patients with chronic musculoskeletal pain conditions.

OBJECTIVE

The objective of this best practice implementation project was to assess and promote exercise-centered self-management strategies in physiotherapy care.

METHODS

JBI's Evidence Implementation Framework, Practical Application of Clinical Evidence System (PACES) audit tool, and Getting Research into Practice (GRiP) method were used. The project was conducted in Germany at the University Hospital of the Brandenburg Medical School in the Department of Physiotherapy. Barriers and facilitators to implementation were identified through qualitative interviews with musculoskeletal pain experts in the team (N  =  5). All team members (N  =  16) completed a 31-item standardized questionnaire to determine compliance with seven audit criteria. The results of the baseline audit informed the implementation strategy. A post-implementation audit was conducted to measure improvements in practice.

RESULTS

Baseline compliance with audit criteria ranged from 0% to 89%. Barriers to implementation included lack of knowledge on self-management facilitation (e.g., assessment of patient capabilities, pain education, goal-setting, self-monitoring, action plan development) and no standardized documentation. The implementation strategy combined interactive educational training with the introduction of two standardized assessment and documentation forms. Moreover, a short-form exercise diary was created to facilitate patient self-monitoring. In the follow-up audit, five of the seven audit criteria improved.

CONCLUSIONS

A combination of interactive educational training, standardized physiotherapy assessment and documentation, and a short-form exercise diary may be appropriate strategies to increase compliance for exercise-related self-management facilitation.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A345.

Structural equation model of knee pain in individuals with knee osteoarthritis-associated knee pain, based on functional capacity, kinesiophobia, muscle thickness, and joint position sense

BACKGROUND

There are several clinical parameters that contribute to knee osteoarthritis (KOA)-associated knee pain and/or its progression such as kinesiophobia, functional capacity, muscle thickness, and joint position sense. The relationship between knee pain and those aforementioned clinical parameters is needed for clear understanding. Therefore, this study constructed the structural equation model of knee pain with the variables of kinesiophobia, functional capacity, muscle thickness, and joint position sense in individuals with KOA-associated knee pain.

METHODS

We examined 200 individuals (74% female) with KOA-associated knee pain. Kinesiophobia, functional capacity test, quadriceps and hamstring muscle thickness, and knee joint position sense in flexion and extension were obtained and served as latent variables to investigate causal relationships with knee pain through structural equation modeling.

RESULTS

All latent variables were fit for the structural model with excellent statistical parameters. The squared multiple correlations' estimate for the model was 0.928. In particular, kinesiophobia, functional capacity test, and hamstring muscle thickness had significant associations with knee pain.

CONCLUSION

Knee pain was associated with kinesiophobia, functional capacity, quadriceps and hamstring muscle thickness, and knee joint position sense. Although this relationship does not establish causality, the findings underscore the importance of adopting an integrated approach when designing preventive interventions or therapeutic strategies for managing knee pain.

Comparison the effect of Otago and chair squat exercises on the fear of falling and the quality of life of the older adults, a clinical trial study

BACKGROUND

Staying at home limits older people's physical activity and increases their fear of falling. Also, their physiological and psychological problems lead to decrease in physical activity, which affects their quality of life.

AIMS

The aim of this study was to help use a cost-effective, and less complicated method to reduce the fear of falling and improve the quality of life of the aged people.

METHODS

A total of 126 aged people (over the age of 60) participated in this study, which lasted 8 weeks (three 45-min sessions per week at home). The participants were divided into three Chair squat, Otago, and control groups randomly. Fear of falling and quality of life scores were evaluated before and after the intervention. The data were analyzed using SPSS software.

RESULTS

Before the study, there was no significant difference between the groups in terms of fear of falling and quality of life. After the intervention, the Otago was more effective than chair squat exercise in reducing the average score of the fear of falling, but there was no significant difference between the intervention groups in terms of quality of life.

DISCUSSION

Both Otago and chair squat exercises were cost-effective and less complicated methods that helped reduce fear of falling and improve the quality of life of the older adults.

CONCLUSION

Performing the Otago and chair squat exercises at home was effective in reducing fear of falling and improving quality of life of the older adults.

CLINICAL TRIAL REGISTRATION

IRCT20150519022320N29 on July21, 2023.

Exploring barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (MyBack project): a qualitative study

PURPOSE

This study aimed to explore potential barriers and facilitators to the adoption of regular exercise practice in patients at risk of a recurrence of low back pain (LBP).

MATERIALS AND METHODS

Eleven patients, who recovered from a previous episode of LBP, participated in two focus groups. The semi-structured interview schedule was informed by the Behaviour Change Wheel and the Theoretical Domains Framework. Focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis was performed by two researchers independently.

RESULTS

Eighteen barriers and 19 facilitators were identified. The most common barriers included "lack of knowledge on how to manage a recurrence of LBP," "lack of behavioural regulation strategies and having other priorities" and "lack of self-efficacy/confidence to practice exercise autonomously and deal with a new episode of LBP." "Knowledge on exercise and recurrences," "regular exercise habits," "having specific behavioural regulation strategies," "exercise practice with others," "willingness to practice exercise and considering it a priority," and "presence of positive emotions related with exercise practice" were the most common facilitators.

CONCLUSIONS

These findings will inform the development of a behaviour change-informed exercise intervention to promote regular exercise practice among patients at risk of a recurrence of LBP.

Short-term effects of exergaming on patients with chronic low back pain: A single-blind randomized controlled trial

BACKGROUND

Exergaming is increasingly popular, but its impact on chronic low back pain (CLBP) remain unclear.

OBJECTIVES

To evaluate the effectiveness of exergaming versus traditional exercise for managing CLBP using the International Classification of Functioning, Disability and Health (ICF) framework.

METHODS

This single-blind, randomized controlled trial included 70 participants with CLBP, who were assigned to either the exergaming or traditional exercise group. Both groups received 2 weeks of treatment with six sessions. Assessments included the Oswestry Disability Index (ODI), range of motion, Hospital Anxiety and Depression Scale (HADS), balance (Biodex Stability System), Fear-Avoidance Beliefs Questionnaire (FABQ), and physical performance tests.

RESULTS

After six sessions over 2 weeks, the exergaming group showed significant improvements over the exercise group in ODI (p < 0.001), chair-rising time (p = 0.001), stair ascent (p = 0.025) and descent times (p < 0.001), flexion (p = 0.005), extension (p = 0.001), balance (p = 0.012), and FABQ subscales (physical activity: p = 0.003; work: p < 0.001) at the 3-month follow-up. Group × time interaction effects favored exergaming for ODI (p = 0.012), chair-rising (p = 0.045), stair ascent (p = 0.010), and descent (p = 0.002) times. While these changes did not meet clinical significance, exergaming was not inferior to traditional exercise in improving spinal motion, physical performance, fear-avoidance beliefs, and disability.

CONCLUSION

Exergaming appears to be a viable supplementary therapy for patients with CLBP, offering benefits across all ICF domains. Future studies with longer intervention durations are needed to assess its long-term effects.

The Knee-SCHOOL: a brief patient-centered multidisciplinary educational program for knee osteoarthritis

Background

Knee osteoarthritis (KOA) is the most common form of arthritis in adults and a leading cause of years lived with disability, representing a significant burden on healthcare worldwide.

Objective

Describe the structure and educational elements of the Knee-SCHOOL, a brief patient-centered multidisciplinary educational program for patients with KOA.

Design

Observational prospective study.

Setting

Academically affiliated rehabilitation outpatient center in Brazil.

Methods

The program consisted of three in-person educational sessions (4.5 hr each) for 55 community dwelling adults, aged ≥50 years, with primary KOA-related pain. Study measures included demographic data (age, sex, and educational level), pain duration (years), pain intensity (visual analogue scale), affected knee (right, left, or both knees), comorbidities (presence of hypertension, diabetes, and hypercholesterolemia), Body Mass Index (BMI), Bristol Stool Scale, Adapted Healthy Eating Index (AHEI), bioelectrical impedance, daytime sleepiness, and the impact of the KOA on pain, symptoms, activities of daily living, recreation, and quality of life. Participants attended educational sessions delivered by a multidisciplinary team (two physicians, two nurses, two physical therapists, one occupational therapist, one dietitian, one psychologist, one social worker, and one physical educator) addressing several aspects of KOA. They also participated in supervised exercise practice and a home exercise program.

Results

Fifty-five subjects completed the study. The mean age was 67.73 (± 7.73) years; most were females (70.9%), 92.7% had bilateral KOA, with mean pain duration of 12.41 (± 10.17) years. The mean BMI was 32.52 (± 5.99), 65.5% were obese, and 96.4% reported an inadequate diet. KOA had a more negative impact on sports, recreation and quality of life. Daytime sleepiness was uncommon. The mean pain intensity, measured with visual analogue scale, score reduced from 5.52 (± 2.11) at baseline to 4.04 (± 2.38) after the program (week 2). The effect size was 0.7 (95% CI 0.32 to 1.07). All participants received the program well, with no drop-out rates or reported adverse events.

Conclusion

The Knee-SCHOOL utilized a multidisciplinary educational approach and an exercise practice addressing multiple aspects of KOA pain. While more studies are needed to assess the longitudinal impact of the program, it was promising in managing pain.

People with short symptom duration of knee osteoarthritis benefit more from exercise therapy than people with longer symptom duration: An individual participant data meta-analysis from the OA trial bank

OBJECTIVE

To investigate whether duration of knee symptoms influenced the magnitude of the effect of exercise therapy compared to non-exercise control interventions on pain and physical function in people with knee osteoarthritis (OA).

METHOD

We undertook an individual participant data (IPD) meta-analysis utilising IPD stored within the OA Trial Bank from randomised controlled trials (RCTs) comparing exercise to non-exercise control interventions among people with knee OA. IPD from RCTs were analysed to determine the treatment effect by considering both study-level and individual-level covariates in the multilevel regression model. To estimate the interaction effect (i.e., treatment x duration of symptoms (dichotomised)), on self-reported pain or physical function (standardised to 0-100 scale), a one-stage multilevel regression model was applied.

RESULTS

We included IPD from 1767 participants with knee OA from 10 RCTs. Significant interaction effects between the study arm and symptom duration (≤1 year vs >1 year, and ≤2 years vs>2 years) were found for short- (∼3 months) (Mean Difference (MD) -3.57, 95%CI -6.76 to -0.38 and -4.12, 95% CI-6.58 to -1.66, respectively) and long-term (∼12 months) pain outcomes (MD -8.33, 95%CI -12.51 to -4.15 and -8.00, 95%CI -11.21 to -4.80, respectively), and long-term function outcomes (MD -5.46, 95%CI -9.22 to -1.70 and -4.56 95%CI -7.33 to-1.80, respectively).

CONCLUSIONS

This IPD meta-analysis demonstrated that people with a relatively short symptom duration benefit more from therapeutic exercise than those with a longer symptom duration. Therefore, there seems to be a window of opportunity to target therapeutic exercise in knee OA.

Exercise-based telerehabilitation in chronic low back pain - a scoping review

BACKGROUND

Low back pain is a major global health problem. Physiotherapy involving exercises is considered first-line treatment. In recent years digital tools including telerehabilitation have increased, but the interventions are diverse. The aim of this study was to map how telerehabilitation approaches are used in studies evaluating exercise-based rehabilitation in patients with chronic low back pain.

METHODS

A systematic literature search was conducted in PubMed, Cinahl and Cochrane Central between January 2017 and January 2024 for original studies on adults, 18 years or older, with chronic low back pain who received exercise-based telerehabilitation.

RESULTS

The database search resulted in 1019 articles. Out of 37 full texts that were screened 28 articles were included in the analysis. The included studies showed a wide variation regarding technological solutions, interventions and outcome measures. The exercise-based telerehabilitation was usually delivered asynchronously via a smartphone application. The most common clinical outcome measure was pain and disability/physical function. Telerehabilitation compared to conventional exercise therapy showed similar clinical improvements.

CONCLUSIONS

This scoping review confirms the heterogeneity within this research area but also contributes by mapping and demonstrating some knowledge gaps in the literature. Further research focusing on synchronous and group interventions are needed. The new technologies described in the included studies provide added value through functional improvements and task redesign.

TRIAL REGISTRATION

OSF https//doi.org/10.17605/OSF.IO/EMKCG.

Home-Based, Low-Intensity, Gamification-Based, Interactive Physical-Cognitive Training for Older Adults Using the ADDIE Model: Design, Development, and Evaluation of User Experience

Background

Declines in physical and cognitive function are natural biological processes, leading to an increased risk of falls. Promising evidence suggests that combined physical-cognitive exercise has beneficial effects in improving both physical and cognitive health. Although moderate-to-high exercise intensity is commonly recommended, it might be impractical for older adults facing physical limitations or contraindications. Thus, low-intensity exercise is a viable option. The main barriers to engaging in exercise in older adults include transportation, time, motivation, and enjoyment. To overcome these challenges, a home-based, gamification-based training system may provide an effective approach to enhance exercise adherence.

Objective

This study aimed to develop and evaluate the usability of a low-intensity, gamification-based, interactive physical-cognitive exercise for older adults in a home-based setting.

Methods

The prototype of a game-based physical-cognitive exercise was created following the ADDIE model (analysis, design, development, implementation, and evaluation) and assessed for user experience in older adults. A total of 15 older adults engaged in the game-based physical-cognitive exercise at home for 60 minutes per day, 3 days per week, for 4 weeks. The usability of the game-based training system was evaluated using the system usability scale (SUS) after completion of a 4-week training program. As for satisfaction, the 8-item Physical Activity Enjoyment Scale (PACES) questionnaire was used to assess participants' enjoyment level after 1 week and 4 weeks of training. Descriptive statistics were used to illustrate the SUS score. A Wilcoxon signed-rank test was used to compare the PACES scores between the first week and the end of the 4-week period, with significance set at P<.05.

Results

As for experts' consensus, the game-based training consisted of 3 games: Ocean Diver, Road Runner, and Moving and Memorizing. The games had 3 levels of difficulty: beginner, intermediate, and advanced. A computer vision-based system was selected as the delivery platform for a home setting. The total SUS score for all participants was mean 87.22 (SD 5.76), indicating the user's perception of the usability of a system ranging from good to excellent. At the end of the 4-week training, the total PACES score was significantly greater than the first week, suggesting an improvement in enjoyment (first week: mean 44.93, SD 3.99 vs fourth week: mean 50.53, SD 4.70; P=.001).

Conclusions

The prototype of low-intensity, gamification-based, interactive physical-cognitive training was designed and developed using the ADDIE model, which included both experts and end users in the process. The findings showed that the exergame prototype was a usable and practical approach for a home-based setting, enhancing older adults' enjoyment and motivation. Further research is warranted to determine the effectiveness of such gamification-based training in promoting physical and cognitive functions.

Effectiveness of strategies to improve adherence to physical therapy in patients with knee and hip osteoarthritis: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of current strategies oriented to increase adherence to physical therapy in subjects with knee and hip osteoarthritis (OA).

MATERIAL AND METHODS

A systematic review of electronic databases was conducted from inception until March 2023. Studies with experimental interventions using strategies to increase adherence to physical therapy programs in subjects with knee or hip OA were included. A meta-analysis compared the effects of such interventions with usual care for adherence-related measures (primary outcome), and functional and pain outcomes, using standardized mean differences (SMD) with a 95% confidence interval (CI). GRADE was used to determine the strength of the resultant evidence and the external validity of the findings.

RESULTS

Fifteen articles, assessing 1,818 participants, were included. The interventions included cognitive-behavior strategies, telephone calls, internet-based interventions, communication technologies, and booster sessions. A meta-analysis revealed that the experimental interventions increased adherence over usual care with a moderate effect size of SMD = 0.39 (95%CI = 0.08-0.71) and moderate certainty in this evidence.

CONCLUSION

Overall, this review supports that the strategies to promote adherence to physical therapy in individuals with knee and hip OA are effective. However, the positive impact on adherence rates does not always translate into improved clinical outcomes.

Barriers and enablers to exercise adherence in people with nonspecific chronic low back pain: a systematic review of qualitative evidence

ABSTRACT

Exercise is a first-line treatment for chronic low back pain (CLBP), reducing pain and disability in the short term. However, exercise benefits decrease over time, with a lack of long-term exercise adherence a potential reason for this. This study aimed to synthesize the perceptions and beliefs of individuals with CLBP and identify their barriers and enablers to exercise adherence. We searched CENTRAL, Embase, CINAHL, SPORTDiscus, PubMed, PsycINFO, and Scopus databases from inception to February 28, 2023, for qualitative studies that explored the factors influencing exercise adherence for people with CLBP. A hybrid approach combining thematic synthesis with the Theoretical Domains Framework was used to analyze data. We assessed methodological quality using the Critical Appraisal Skills Programme checklist and the level of confidence of the themes generated using the Confidence in the Evidence from Reviews of Qualitative Studies. Twenty-three papers (n = 21 studies) were included (n = 677 participants). Four main themes affected exercise adherence: (1) exercise, pain, and the body, (2) psychological factors, (3) social factors, and (4) external factors. These themes contained 16 subthemes that were predominantly both barriers and enablers to exercise adherence. The individual's experiences of barriers and enablers were most appropriately represented across a spectrum, where influencing factors could be a barrier or enabler to exercise adherence, and these could be specific to pre-exercise, during-exercise, and post-exercise situations. These findings may be used to improve exercise adherence and ultimately treatment outcomes in people with CLBP.

Physical Activity Interventions Among Older Adults with Chronic Illnesses: Systematic Review and Network Meta-Analysis

To investigate the individual effectiveness of motivational interviewing, tailor-made interventions, social context-related interventions, shared decision making, and monitoring & feedback versus active- and passive control groups on physical activity level among older adults at short-, middle-, and long term. Secondary aim is to compare the effectiveness of interventions using a single motivational strategy versus interventions combining multiple motivational strategies. Literature search of PubMed, EMBASE, CINAHL, and PEDro databases using keywords and subject headings. Randomized controlled trials comparing two or more arms, with one arm focused on motivational strategies influencing physical activity were included. We identified 20,690 titles, of which 51 (comprising 11,596 participants) were included. Methodological quality and quality of evidence was evaluated using PEDro scale and GRADE approach. Outcomes were physical activity levels measured by objective- or subjective instruments at 3-, 6-, and 12 months follow-up. Standardized mean differences between intervention- and control groups were used as the mode of the analyses. For primary outcome, 6 months follow-up, pooled data demonstrated a statistically significant trend for higher effectiveness interventions using multiple motivational strategies compared with an active control intervention, while other singular motivational strategies did not show similar results for this comparison. The quality of the body of evidence was graded as very low for all motivational strategies. In our search, we have used broad in- and exclusion criteria for eligible studies regarding population characteristics resulting in a wide variety of conditions and illnesses included in our review which warrants a better representation of daily clinical practice. However, this led to data being pooled from a wide variety of different study populations and settings, content of interventions and outcome measures, increasing the heterogeneity of study characteristics. Interventions combining multiple motivational strategies show a trend to be more effective than using singular treatment strategies, although the optimal composition remains unclear.

Framing Physical Literacy for Adults Through a Rehabilitation Lens: An Expert Consensus Study

Research indicates a positive relationship between physical literacy and healthy aging; however, there is no consensus on the components required to become a physically literate adult. The objective of this study was to understand how physical literacy for adults with chronic conditions is characterized from the perspective of healthcare professionals. Physiotherapy leaders and physical literacy researchers within North America were invited to an online consensus panel and presented with questions related to physical literacy and rehabilitation. A nominal group technique was used for idea generation, clarification, and ranking. Confidence and safety with movements, motivation and commitment to physical activity, the ability to self-monitor changes in function, and understanding the benefits of physical activity were key components when defining physical literacy. There is a need to reconceptualize physical literacy to include the rehabilitation needs of adults living with chronic conditions, and to design programs that promote physical literacy to enhance function and mobility.

Using Resistance-Band Tests to Evaluate Trunk Muscle Strength in Chronic Low Back Pain: A Test-Retest Reliability Study

Exercise is a front-line intervention to increase functional capacity and reduce pain and disability in people with low strength levels or disorders. However, there is a lack of validated field-based tests to check the initial status and, more importantly, to control the process and make tailored adjustments in load, intensity, and recovery. We aimed to determine the test-retest reliability of a submaximal, resistance-band test to evaluate the strength of the trunk stability muscles using a portable force sensor in middle-aged adults (48 ± 13 years) with medically diagnosed chronic low back pain and healthy peers (n = 35). Participants completed two submaximal progressive tests of two resistance-band exercises (unilateral row and Pallof press), consisting of 5 s maintained contraction, progressively increasing the load. The test stopped when deviation from the initial position by compensation movements occurred. Trunk muscle strength (CORE muscles) was monitored in real time using a portable force sensor (strain gauge). Results revealed that both tests were highly reliable (intra-class correlation [ICC] > 0.901) and presented low errors and coefficients of variation (CV) in both groups. In particular, people with low back pain had errors of 14-19 N (CV = 9-12%) in the unilateral row test and 13-19 N (CV = 8-12%) in the Pallof press. No discomfort or pain was reported during or after the tests. These two easy-to-use and technology-based tests result in a reliable and objective screening tool to evaluate the strength and trunk stability in middle-aged adults with chronic low back pain, considering an error of measurement < 20 N. This contribution may have an impact on improving the individualization and control of rehabilitation or physical training in people with lumbar injuries or disorders.

Booster visits in the management of the acute musculoskeletal injuries: Transforming care to improve outcomes-A perspective review

The current healthcare delivery system for patients with acute musculoskeletal injury is failing. Current rehabilitation management of acute musculoskeletal injury typically includes physical therapy, focused on management of impairments, with an eventual transition to functional activities and release to prior level of function. At that point, formal physical therapy is often discontinued, despite the knowledge that a high percentage of patients fail to maintain preinjury level of activity and often reduce participation in regular physical activity. Further, for those who attempt to return to prior levels of pivoting and cutting activities, there is a high second injury rate. The long-term human experience is compromised by the current model of care which terminates at the point of transition to activity. This model of care fails to meet the continued needs of these patients and may result in long term deficits and potential disability. Extended care models include intermittent follow up visits after discharge from an acute episode of care and have been efficacious and cost effective in some patient populations with musculoskeletal conditions. Specifically, a type of extended care model, labeled "booster sessions," represents an opportunity to provide structured, intermittent care to assist in a smooth transition back to function, following an acute episode of care and promote a healthier life outcome. This perspective review will discuss the opportunity to transform acute musculoskeletal care to booster visit care model in an attempt to develop a more efficacious and cost-effective system of care which could be generalizable to all musculoskeletal conditions.

Appropriateness of exercise therapy delivery in chronic low back pain management: cross-sectional online survey of physiotherapy practice in Germany

BACKGROUND

In Germany, exercise therapy represents the most commonly prescribed physiotherapy service for non-specific, chronic low back pain (NSCLBP). So far, little is known about current practice patterns of German physiotherapists in delivering this intervention. Thus, the aim of this study was to investigate the appropriateness of exercise therapy delivered to NSCLBP patients in German physiotherapy care and to identify practitioner-related drivers of appropriate exercise delivery.

METHODS

We used a vignette-based, exploratory, cross-sectional, online-survey study design (76-items; data collection between May and July 2023). Eligible participants were required to hold a professional degree in physiotherapy and were required to be practicing in Germany. Access links to anonymous online surveys were spread via established German physiotherapy networks, educational platforms, social media, e-mail lists, and snowball sampling. Appropriateness of exercise therapy was calculated by an equally weighted total score (400 points) including scales on shared-decision-making, exercise dose selection, pain knowledge and self-management promotion. "Appropriate exercise delivery" was determined by a relative total score achievement of > 80%. "Partly appropriate exercise delivery" was determined by a relative total score achievement of 50-79%, and "inappropriate exercise delivery" by a score achievement of < 50%. Practitioner-related drivers of exercise appropriateness were calculated by bivariate and multiple linear regression analyses.

RESULTS

11.9% (N = 35) of 298 physiotherapists' exercise delivery was considered "appropriate", 83.3% (N = 245) was "partly appropriate", and 4.8% (N = 14) was "inappropriate". In the final multiple regression model, most robust parameters positively influencing appropriate delivery of exercise therapy were increased scientific literacy (B = 10.540; 95% CI [0.837; 20.243]), increased average clinical assessment time (B = 0.461; 95% CI [0.134; 0.789]), increased self-perceived treatment competence (B = 7.180; 95% CI [3.058; 11.302], and short work experience (B = - 0.520; 95% CI [-0.959; - 0.081]).

CONCLUSION

Appropriate exercise delivery in NSCLBP management was achieved by only 11.9% of respondents. However, the vast majority of 95.2% of respondents was classified to deliver exercise therapy partly appropriate. Long work experience seemed to negatively affect appropriate exercise delivery. Positive influences were attributed to scientific literacy, the average clinical assessment time per patient as well as the perceived treatment competence in NSCLBP management.

REGISTRATION

Open science framework: https://doi.org/10.17605/OSF.IO/S76MF .

Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Adherence to physiotherapeutic treatment and recommendations is crucial to achieving planned goals and desired health outcomes. This overview of systematic reviews synthesises the wide range of additional interventions and behaviour change techniques used in physiotherapy, exercise therapy and physical therapy to promote adherence and summarises the evidence of their efficacy.

METHODS

Seven databases (PEDro, PubMed, Cochrane Library, Web of Science, Scopus, PsycINFO and CINAHL) were systematically searched with terms related to physiotherapy, motivation, behaviour change, adherence and efficacy (last searched on January 31, 2023). Only systematic reviews of randomised control trials with adults were included. The screening process and quality assessment with AMSTAR-2 were conducted independently by the two authors. The extracted data was synthesised narratively. In addition, four meta-analyses were pooled in a panoramic meta-analysis.

RESULTS

Of 187 reviews identified in the search, 19 were included, comprising 205 unique trials. Four meta-analyses on the effects of booster sessions, behaviour change techniques, goal setting and motivational interventions showed a significantly small overall effect (SMD 0.24, 95% CI 0.13, 0.34) and no statistical heterogeneity (I2 = 0%) in the panoramic meta-analysis. Narrative synthesis revealed substantial clinical and methodological diversity. In total, the certainty of evidence is low regarding the efficacy of the investigated interventions and techniques on adherence, due to various methodological flaws. Most of the RCTs that were included in the reviews analysed cognitive and behavioural interventions in patients with musculoskeletal diseases, indicating moderate evidence for the efficacy of some techniques, particularly, booster sessions, supervision and graded exercise. The reviews provided less evidence for the efficacy of educational and psychosocial interventions and partly inconsistent findings. Most of the available evidence refers to short to medium-term efficacy. The combination of a higher number of behaviour change techniques was more efficacious.

CONCLUSIONS

The overview of reviews synthesised various potentially efficacious techniques that may be combined for a holistic and patient-centred approach and may support tailoring complex interventions to the patient's needs and dispositions. It also identifies various research gaps and calls for a more holistic approach to define and measure adherence in physiotherapy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021267355.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update

INTRODUCTION

Hip and knee osteoarthritis (OA) are increasingly common with a significant impact on individuals and society. Non-pharmacological treatments are considered essential to reduce pain and improve function and quality of life. EULAR recommendations for the non-pharmacological core management of hip and knee OA were published in 2013. Given the large number of subsequent studies, an update is needed.

METHODS

The Standardised Operating Procedures for EULAR recommendations were followed. A multidisciplinary Task Force with 25 members representing 14 European countries was established. The Task Force agreed on an updated search strategy of 11 research questions. The systematic literature review encompassed dates from 1 January 2012 to 27 May 2022. Retrieved evidence was discussed, updated recommendations were formulated, and research and educational agendas were developed.

RESULTS

The revised recommendations include two overarching principles and eight evidence-based recommendations including (1) an individualised, multicomponent management plan; (2) information, education and self-management; (3) exercise with adequate tailoring of dosage and progression; (4) mode of exercise delivery; (5) maintenance of healthy weight and weight loss; (6) footwear, walking aids and assistive devices; (7) work-related advice and (8) behaviour change techniques to improve lifestyle. The mean level of agreement on the recommendations ranged between 9.2 and 9.8 (0-10 scale, 10=total agreement). The research agenda highlighted areas related to these interventions including adherence, uptake and impact on work.

CONCLUSIONS

The 2023 updated recommendations were formulated based on research evidence and expert opinion to guide the optimal management of hip and knee OA.

Contexts, behavioural mechanisms and outcomes to optimise therapeutic exercise prescription for persistent low back pain: a realist review

OBJECTIVE

Therapeutic exercises are a core treatment for low back pain (LBP), but it is uncertain how rehabilitative exercise facilitates change in outcomes. Realist reviews explore how the context (C) of certain settings or populations and underlying mechanisms (M) create intended or unintended outcomes (O). Our objective was to explore and understand the behavioural mechanisms by which therapeutic exercise creates change in outcomes of adherence, engagement and clinical outcomes for patients with LBP.

METHODS

This was a realist review reported following the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidance. We developed initial programme theories, modified with input from a steering group (experts, n=5), stakeholder group (patients and clinicians, n=10) and a scoping search of the published literature (n=37). Subsequently, an information specialist designed and undertook an iterative search strategy, and we refined and tested CMO configurations.

RESULTS

Of 522 initial papers identified, 75 papers were included to modify and test CMO configurations. We found that the patient-clinician therapeutic consultation builds a foundation of trust and was associated with improved adherence, engagement and clinical outcomes, and that individualised exercise prescription increases motivation to adhere to exercise and thus also impacts clinical outcomes. Provision of support such as timely follow-up and supervision can further facilitate motivation and confidence to improve adherence to therapeutic exercises for LBP.

CONCLUSIONS

Engagement in and adherence to therapeutic exercises for LBP, as well as clinical outcomes, may be optimised using mechanisms of trust, motivation and confidence. These CMO configurations provide a deeper understanding of ways to optimise exercise prescription for patients with LBP.

Physical Activity Supported by Low-Cost Mobile Technology for Back Pain (PAT-Back) to Reduce Disability in Older Adults: Results of a Feasibility Study

OBJECTIVE

The purpose of this study was to evaluate the feasibility of a randomized controlled trial investigating the effectiveness of a multimodal program (PAT-Back) compared to best practice advice on pain and disability in older adults with chronic low back pain (LBP) in primary care.

METHODS

This feasibility study took place in Fortaleza, Northeast Brazil. The PAT-Back intervention consisted of a program including exercises, pain education, and motivational text messages for the in-home component. The control group received an evidence-based educational booklet. Feasibility outcomes were recruitment, adherence and retention rates, level of difficulty of the education and intervention content, perception of utility of mobile technology, and adverse events. The feasibility criteria were previously defined.

RESULTS

A total of 248 people were screened, of which 46 older adults were eligible. The retention rate was high (100% in the PAT-Back group and 95% in the control group). The adherence rate to intervention was partially met (60%), whereas the adherence rate to unsupervised exercises was adequate (75%), and perception about safety to perform home exercise was partially acceptable (70%) in the PAT-Back group. In addition, 100% of older adults reported which text messages motivated them to perform the exercises in the PAT-Back group. Difficulty reported by participants in understanding and performing the intervention was small in both groups. Six participants reported transient adverse events in both groups.

CONCLUSION

Older adults accepted both interventions. Results demonstrated that the program is feasible, although minor changes targeting adherence and safety in home exercise are needed.

IMPACT

This feasibility study supports progression to a full trial investigating the effectiveness of a multimodal program (PAT-Back) on pain and disability in older adults with chronic LBP within a primary health care setting in low to middle income countries where such data from the older population are scarce and the burden of LBP is increasing.

Predictors of real-world adherence to prescribed home exercise in older patients with a risk of falling: A prospective observational study

Objectives

Using a multi-ethnic Asian population, this study assessed adherence to prescribed home exercise programs, explored factors predicting adherence, and evaluated whether home exercise adherence was associated with physical activity.

Methods

A prospective cohort study was conducted in 68 older adults (aged ≥65 years) from two geriatric outpatient clinics in Singapore, who were receiving tailored home exercises while undergoing 6 weeks of outpatient physical therapy for falls prevention. Adherence was measured as the percentage of prescribed sessions completed. Predictor variables included sociodemographic factors, clinical characteristics, intervention-specific factors, and physical and psychosocial measures. Multivariable linear regressions were performed to develop a model that best predicted adherence to prescribed exercise. Physical activity levels, measured by accelerometry, were analyzed by cross-sectional univariate analysis at 6 weeks.

Results

The mean adherence rate was 65% (SD 34.3%). In the regression model, the number of medications [B = 0.360, 95% CI (0.098-0.630)], social support for exercising [B = 0.080, 95% CI (0.015-0.145)], and self-efficacy for exercising [B = -0.034, 95% CI (-0.068-0.000)] significantly explained 31% (R 2 = 0.312) of the variance in exercise adherence. Older adults with better adherence took more steps/day at 6 weeks [B = 0.001, 95% CI (0.000-0.001)].

Conclusions

Low adherence to home exercise programs among older adults in Singapore, emphasizing the need for improvement. Counterintuitively, older adults with more medications, lower exercise self-efficacy, but with greater social support demonstrated higher adherence. Addressing unmet social support needs is crucial for enhancing adherence rates and reducing fall risks.

Improving Adherence to Physical Therapy in the Development of Serious Games: Conceptual Framework Design Study

BACKGROUND

Insufficient levels of treatment adherence can have adverse effects on the outcomes of physical rehabilitation. To address this issue, alternative approaches to traditional therapies, such as serious games, have been designed to enhance adherence. Nevertheless, there remain gaps in the development of serious games concerning the effective implementation of motivation, engagement, and the enhancement of treatment adherence.

OBJECTIVE

This study aims to design a conceptual framework for the development of serious games that incorporate essential adherence factors to enhance patient compliance with physical rehabilitation programs.

METHODS

We formulated a conceptual framework using iterative techniques inspired by a conceptual framework analysis. Initially, we conducted a comprehensive literature review, concentrating on the critical adherence factors in physical rehabilitation. Subsequently, we identified, categorized, integrated, and synthesized the concepts derived from the literature review to construct the conceptual framework.

RESULTS

The framework resembles a road map, comprising 3 distinct phases. In the initial phase, the patient's characteristics are identified through an initial exploration. The second phase involves the development of a serious game, with a focus on enhancing treatment adherence by integrating the key adherence factors identified. The third phase revolves around the evaluation of the serious game. These phases are underpinned by 2 overarching themes, namely, a user-centered design and the GameFlow model.

CONCLUSIONS

The conceptual framework offers a detailed, step-by-step guide for creating serious games that incorporate essential adherence factors, thereby contributing to improved adherence in the physical rehabilitation process. To establish its validity, further evaluations of this framework across various physical rehabilitation programs and user groups are necessary.

The influence of the significant other on treatment adherence in chronic pain management: a qualitative analysis

Objectives. Adherence to treatment recommendations is critical for optimising quality of life for individuals with chronic pain, however adherence rates are low. This study explores the role that significant others are perceived to play in supporting or impeding treatment adherence, as well as examining patient views of the impact of their adherence regimes on their significant others.Design. 25 treatment seeking adults with chronic pain, who were currently living with a romantic partner or adult family member, took part in individual semi-structured interviews.Main outcome measures Interviews were transcribed verbatim and analysed using thematic analysis.Results. Three treatment adherence support themes emerged: social support (emotional, instrumental), positive social control, and supporting autonomy. Participants did not perceive significant others as having any negative influence on their adherence. By contrast, patients perceived that their adherence behaviors had both positive and negative effects on their significant others.Conclusions. These data present an encouraging perspective on the interpersonal context of coping with chronic pain. Significant others facilitated adherence in a range of ways. Future research identifying how best to integrate significant other support into patient self-management programs is needed, in order to lift the poor treatment adherence rates that are noted in the literature.

Interpretation threshold values for patient-reported outcomes in patients participating in a digitally delivered first-line treatment program for hip or knee osteoarthritis

Objective

Establish proportions of patients reporting important improvement, acceptable symptoms and treatment failure and define interpretation threshold values for pain, patient-reported function and quality-of-life after participating in digital first-line treatment including education and exercise for hip and knee osteoarthritis (OA).

Methods

Observational study. Responses to the pain Numeric Rating Scale (NRS, 0-10 best to worst), Knee injury and Osteoarthritis Outcome Score 12 (KOOS-12) and Hip disability and Osteoarthritis Outcome Score 12 (HOOS-12, both 0-100 worst to best) were obtained for 4383 (2987) and 2041 (1264) participants with knee (hip) OA at 3 and 12 months post intervention. Threshold values for Minimal Important Change (MIC), Patient Acceptable Symptom State (PASS) and Treatment Failure (TF) were estimated using anchor-based predictive modeling.

Results

70-85% reported an important improvement in pain, function and quality of life after 3 and 12 months follow-up. 42% (3 months) and 51% (12 months) considered their current state as satisfactory, whereas 2-4% considered treatment failed. MIC values were -1 (NRS) and 0-4 (KOOS/HOOS-12) across follow-ups and joint affected. PASS threshold value for NRS was 3, and 53-73 for the KOOS/HOOS-12 subscales Corresponding values for TF were 5 (NRS) and 34-55 (KOOS/HOOS-12). Patients with more severe pain at baseline had higher MIC scores and accepted poorer outcomes at follow-ups.

Conclusion

Threshold estimates aid in the interpretation of outcomes after first-line OA interventions assessed with NRS Pain and KOOS/HOOS-12. Baseline pain severity is important to consider when interpreting threshold values after first-line interventions in these patients.

Absence of Improvement With Exercise in Some Patients With Knee Osteoarthritis: A Qualitative Study of Responders and Nonresponders

OBJECTIVE

To compare the perceptions of patients about why they did, or did not, respond to a physical therapist-supported exercise and physical activity program.

METHODS

This was a qualitative study within a randomized controlled trial. Twenty-six participants (of 40 invited) with knee osteoarthritis sampled according to response (n = 12 responders, and 14 nonresponders based on changes in both pain and physical function at 3 and 9 months after baseline) to an exercise and physical activity intervention. Semistructured individual interviews were conducted. Inductive thematic analysis was undertaken within each subgroup using grounded theory principles. A deductive approach compared themes and subthemes across subgroups. Findings were triangulated with quantitative data.

RESULTS

(Sub)themes common to responders and nonresponders included the intervention components that facilitated engagement, personal attitudes and expectations, beliefs about osteoarthritis and exercise role, importance of adherence, and perceived strength gains with exercise. In contrast to responders who felt empowered to self-manage, nonresponders accepted responsibility for lack of improvement in pain and function with exercise, acknowledging that their adherence to the intervention was suboptimal (confirmed by quantitative adherence data). Nonresponders believed that their excess body weight (supported by quantitative data) contributed to their outcomes, encountered exercise barriers (comorbidities, stressors, and life events), and perceived that the trial measurement tools did not adequately capture their response to exercise.

CONCLUSION

Responders and nonresponders shared some similar perceptions of exercise. However, along with perceived limitations in trial outcome measurements, nonresponders encountered challenges with excess weight, comorbidities, stressors, and life events that led to suboptimal adherence and collectively were perceived to contribute to nonresponse.

Low back pain and osteoarthritis pain: a perspective of estrogen

Low back pain (LBP) is the world's leading cause of disability and is increasing in prevalence more rapidly than any other pain condition. Intervertebral disc (IVD) degeneration and facet joint osteoarthritis (FJOA) are two common causes of LBP, and both occur more frequently in elderly women than in other populations. Moreover, osteoarthritis (OA) and OA pain, regardless of the joint, are experienced by up to twice as many women as men, and this difference is amplified during menopause. Changes in estrogen may be an important contributor to these pain states. Receptors for estrogen have been found within IVD tissue and nearby joints, highlighting the potential roles of estrogen within and surrounding the IVDs and joints. In addition, estrogen supplementation has been shown to be effective at ameliorating IVD degeneration and OA progression, indicating its potential use as a therapeutic agent for people with LBP and OA pain. This review comprehensively examines the relationship between estrogen and these pain conditions by summarizing recent preclinical and clinical findings. The potential molecular mechanisms by which estrogen may relieve LBP associated with IVD degeneration and FJOA and OA pain are discussed.

The effectiveness of exercise with behavior change techniques in people with knee osteoarthritis: A systematic review with meta-analysis

OBJECTIVE

The purpose of this systematic review with meta-analysis was to examine the effectiveness of exercise with behavior change techniques (BCTs) on core outcome sets in people with knee osteoarthritis.

LITERATURE SURVEY

We searched randomized controlled trials (RCTs) in eight databases (MEDLINE, Embase, CENTRAL, CINAHL, PsycINFO, PEDro, ICTRP, and ClinicalTrials.gov) up to November 4, 2021.

METHODOLOGY

Eligible participants were people with knee osteoarthritis. The intervention was exercise with BCTs. Primary outcomes included physical function, quality of life (QOL) 6 to 12 months after intervention, and adverse events. Secondary outcomes were knee pain, exercise adherence, mobility, and self-efficacy 3 months or more after intervention. The bias risk was assessed using the Risk of Bias 2 tool. The random-effects model was used for the meta-analysis.

SYNTHESIS

We found 16 individual BCTs, and 37.7% of trials used a single BCT. For meta-analysis, we included 21 RCTs (n = 1623). Most outcomes had a very low certainty of evidence, and the risk of bias was the consistent reason for downgrading evidence levels. The standardized mean difference (SMD) with 95% confidence interval (95% CI) was 0.00 (-0.24, 0.24) in physical function, 0.33 (-0.51, 1.17) in exercise adherence, and 0.04 (-0.39, 0.47) in self-efficacy. The risk ratio (95% CI) of adverse events was 3.6 (0.79, 16.45). QOL was not pooled due to insufficient data (very low certainty of evidence). In contrast, the SMD (95% CI) for knee pain reduction and mobility improvement was -0.33 (-0.53, -0.13) and 0.21 (-0.05, 0.47) with moderate and low certainty of evidence, respectively.

CONCLUSION

The evidence is inconclusive regarding the effectiveness of BCTs with exercises on core outcome sets. Further research should explore the effectiveness of BCTs with valid design.

PROTOCOL REGISTRATION

PROSPERO (CRD42020212904).

Mechanisms of action of therapeutic exercise for knee and hip OA remain a black box phenomenon: an individual patient data mediation study with the OA Trial Bank

OBJECTIVES

To evaluate mediating factors for the effect of therapeutic exercise on pain and physical function in people with knee/hip osteoarthritis (OA).

METHODS

For Subgrouping and TargetEd Exercise pRogrammes for knee and hip OsteoArthritis (STEER OA), individual participant data (IPD) were sought from all published randomised controlled trials (RCTs) comparing therapeutic exercise to non-exercise controls in people with knee/hip OA. Using the Counterfactual framework, the effect of the exercise intervention and the percentage mediated through each potential mediator (muscle strength, proprioception and range of motion (ROM)) for knee OA and muscle strength for hip OA were determined.

RESULTS

Data from 12 of 31 RCTs of STEER OA (1407 participants) were available. Within the IPD data sets, there were generally statistically significant effects from therapeutic exercise for pain and physical function in comparison to non-exercise controls. Of all potential mediators, only the change in knee extension strength was statistically and significantly associated with the change in pain in knee OA (β -0.03 (95% CI -0.05 to -0.01), 2.3% mediated) and with physical function in knee OA (β -0.02 (95% CI -0.04 to -0.00), 2.0% mediated) and hip OA (β -0.03 (95% CI -0.07 to -0.00), no mediation).

CONCLUSIONS

This first IPD mediation analysis of this scale revealed that in people with knee OA, knee extension strength only mediated ±2% of the effect of therapeutic exercise on pain and physical function. ROM and proprioception did not mediate changes in outcomes, nor did knee extension strength in people with hip OA. As 98% of the effectiveness of therapeutic exercise compared with non-exercise controls remains unexplained, more needs to be done to understand the underlying mechanisms of actions.

Effect of sit-to-stand-based training on muscle quality in sedentary adults: a randomized controlled trial

The aim of this study was to compare the effects of sit-to-stand (STS) training programs with 5 vs. 10 repetitions on muscle architecture and muscle function in sedentary adults. Sixty participants were randomly assigned into three groups: five-repetition STS (5STS), 10-repetition STS (10STS), or a control group (CG). Participants performed three sets of five or 10 repetitions of the STS exercise three times per week for 8 weeks. Before and after 8 weeks, all groups performed ultrasound measures to evaluate muscle thickness (MT), pennation angle (PA), and fascicle length (FL), and the five-repetition STS test to estimate the relative STS power and muscle quality index (MQI). After 8 weeks, both experimental groups improved MQI (40-45%), relative STS power (29-38%), and MT (8-9%) (all p < 0.001; no differences between the 5STS vs. 10STS groups). These improvements in both groups resulted in differences regarding the CG, which did not present any change. In addition, only the 5STS group improved PA (15%; p = 0.008) without differences to the 10STS and CG.This suggests that STS training is time-effective and low-cost for improving muscle function and generating adaptations in muscle architecture.

Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis

BACKGROUND

Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both.

METHODS

We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049).

FINDINGS

Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0-100 scale (with 100 corresponding to worst pain), with a difference of -6·36 points (95% CI -8·45 to -4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, -3·77 points (-5·97 to -1·57, BoS 30·0%, τ2 14·4) in the medium term, and -3·43 points (-5·18 to -1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0-100 scale (with 100 corresponding to worst physical function), with a difference of -4·46 points in the short term (95% CI -5·95 to -2·98, BoS 10·5%, τ2 10·1), -2·71 points in the medium term (-4·63 to -0·78, BoS 33·6%, τ2 11·9), and -3·39 points in the long term (-4·97 to -1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks).

INTERPRETATION

There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit.

FUNDING

Chartered Society of Physiotherapy Charitable Trust and the National Institute for Health and Care Research.

The Psychologically Informed Practice Consultation Roadmap: A Clinical Implementation Strategy

Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar.

[Digital tools in musculoskeletal rehabilitation]

The demographic transition in combination with the increasing demands of society and a growing shortage of skilled workers are leading to a shortage of care in musculoskeletal rehabilitation, especially in times of the pandemic. Digital interventions represent an opportunity to reintegrate patients with musculoskeletal dysfunctions into everyday life. The changes to the legal basis enable physicians and therapists to support the rehabilitation of their patients with reimbursable apps and digital applications and to permanently integrate learned skills into their daily lives. Telerehabilitation technologies, apps, telerobotics and mixed reality offer the opportunity to complement and optimize existing care structures and to redesign specialized therapeutic home visits with modern technology in a new and contemporary way.

Spondylolisthesis and mismatch deformity affect outcomes after total knee arthroplasty

BACKGROUND

Little published data currently exist regarding the potential relationships between spondylolisthesis, mismatch deformity, and clinical outcomes following total knee arthroplasty (TKA). We hypothesize that preexisting spondylolisthesis will result in decreased functional outcomes after TKA.

METHODS

This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure the degree of spondylolisthesis. Ninety-five TKAs were subsequently available for inclusion and divided into two groups: those with spondylolisthesis and those without. Within the spondylolisthesis cohort, pelvic incidence (PI) and lumbar lordosis (LL) were calculated on lateral radiographs to determine the difference (PI-LL). Radiographs with PI-LL > 10° were then categorized as having mismatch deformity (MD). The following clinical outcomes were compared between the groups: need for manipulation under anesthesia (MUA), total postoperative arc of motion (AOM) both pre-MUA or post-MUA/revision, incidence of flexion contracture, and a need for later revision.

RESULTS

Forty-nine TKAs met the spondylolisthesis criteria, while 44 did not have spondylolisthesis. There were no significant differences in gender, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with spondylolisthesis and concomitant MD were more likely to have MUA (p = 0.016), ROM < 0-120 (p < 0.014), and a decreased AOM (p < 0.02) without interventions.

CONCLUSION

Preexisting spondylolisthesis by itself may not have adverse effect clinical results following TKA. However, spondylolisthesis increases the likelihood of developing MD. In those with both spondylolisthesis and concomitant mismatch deformities, patients had statistically and clinically significantly decreased in postoperative ROM/AOM and increased need for MUA. Surgeons should consider clinical/radiographic assessments of patients with chronic back pain who present for total joint arthroplasty.

LEVEL OF EVIDENCE

Level 3.

Comparison of Functional Outcomes between Supervised Rehabilitation and Telerehabilitation in Female Patients with Patellofemoral Pain Syndrome during the COVID-19 Pandemic

Patellofemoral pain syndrome (PFPS) is a common cause of anterior knee pain, and therapeutic exercises are recommended. During the COVID-19 pandemic, despite recommendations on the importance of telerehabilitation, insufficient studies have investigated functional outcomes between supervised rehabilitation and telerehabilitation in patients with PFPS. This study aimed to compare the muscle strength, muscle activation time, and patient-reported outcomes between supervised rehabilitation and telerehabilitation in female patients with PFPS. A total of 61 patients (supervised, n = 30; telerehabilitation, n = 31) participated. Muscle strength and activation time of the quadriceps and hamstrings were measured using an isokinetic device. Hip muscle strength was evaluated using a hand-held dynamometer. Patient-reported outcomes were measured using the visual analog scale (VAS) for pain, Kujala Anterior Knee Pain Scale (AKPS) for functional ability, and Tampa scale for kinesiophobia (TSK-11). No significant differences were found in muscle strength, muscle activation time, or patient-reported outcomes of the involved knees between the two groups (p > 0.05). In addition, the rate of change in all parameters did not significantly differ between the two groups (p > 0.05). Telerehabilitation, such as a home-exercise program supervised by physical therapists, may be as effective as supervised rehabilitation in improving functional outcomes in female patients with PFPS.

Making the current non-surgical treatments for knee osteoarthritis more effective: Solutions from a diverse patient group

OBJECTIVE

To examine patient perceived solutions to barriers to effective non-surgical knee osteoarthritis (OA) treatments in a diverse racial/ethnic group.

METHODS

Nominal groups were conducted with consecutive patients with knee OA at a medical center clinic, oversampling for African Americans with knee OA. Participants discussed potential solutions and rank-ordered their concerns.

RESULTS

Thirteen nominal groups with 46 knee OA patients were conducted with mean age, 60.8 years (standard deviation [sd], 10.0) and knee OA duration, 8.1 years (sd, 5.4); 22% were men, and 56% were African American. The following solutions were in the top three ranked solutions in 13 NGTs: (A) more research, effective and/or safer new medications/treatments, and joint cartilage restoration (8 groups; 15% votes [43/276]); (B) early diagnosis (2 groups; 7% votes [20/276]); (C) better and more effective communication (5 groups; 10% votes [29/276]); (D) public and patient education (4 groups; 8% votes [22/276]); (E) motivation and behavioral modification (4 groups; 9% votes [26/276]); (F) team approach (1 group; 1% votes [2/276]); (G) personalized medicine (6 groups; 8% votes [24/276]); (H) cheaper and more affordable medications and treatments (3 groups; 5% votes [15/276]).

CONCLUSIONS

A diverse group of participants with knee OA identified several solutions to barriers to the effectiveness of current knee OA treatments. This new knowledge can inform the development and implementation of future interventions to improve the outcomes of people with knee OA.

Exercise and education vs intra-articular saline for knee osteoarthritis: a 1-year follow-up of a randomized trial

OBJECTIVE

To assess the longer-term effect of the Good Life with osteoarthritis in Denmark (GLAD) exercise and education program relative to open-label placebo (OLP) on changes from baseline in core outcomes in individuals with knee osteoarthritis (OA).

METHODS

In this 1-year follow-up of an open-label, randomized trial, patients with symptomatic and radiographically confirmed knee OA were monitored after being randomized to either the 8-week GLAD program or OLP given as 4 intra-articular saline injections over 8 weeks. The primary outcome was the change from baseline in the Knee injury and Osteoarthritis Outcome Score questionnaire (KOOS) pain subscale after 1 year in the intention-to-treat population. Key secondary outcomes were the KOOS function and quality of life subscales, and Patients' Global Assessment of disease impact.

RESULTS

206 adults were randomly assigned: 102 to GLAD and 104 to OLP, of which only 137 (63/74 GLAD/OLP) provided data at 1 year. At one year the mean changes in KOOS pain were 8.4 for GLAD and 7.0 for OLP (Difference: 1.5 points; 95% CI -2.6 to 5.5). There were no between-group differences in any of the secondary outcomes.

CONCLUSIONS

In this 1-year follow-up of individuals with knee OA, the 8-week GLAD program and OLP both provided minor longer-term benefits with no group difference. These results require confirmation given the significant loss to follow-up.

TRIAL REGISTRATION NUMBER

NCT03843931.

The effect of rhythmic movement on physical and cognitive functions among cognitively healthy older adults: A systematic review and meta-analysis

OBJECTIVE

To explore the effects of rhythmic movement interventions on the physical and cognitive functions among cognitively healthy older adults.

METHODS

We searched PubMed, Web of Science, Cochrane Library, EMBASE, CNKI, CBM, Wanfang Data, and VIP databases from inception to March 30, 2022. The inclusion criteria were: ① randomized controlled trials (RCTs); ② older adults (aged ≥ 60 years) without cognitive impairments or neurological or neurodegenerative diseases; ③ intervention: rhythmic movement (rhythmic exercise or physical activities performed to music); ④ outcomes: physical or cognitive function. Overall, 44 RCTs across 20 countries (n = 2752 participants) were included.

RESULTS

An association was found between rhythmic movement and improved physical function (mobility, cardiopulmonary endurance, muscle strength, flexibility, and balance), global cognitive function, and quality of life (QOL). The physical function outcomes suggested additional significant benefits when using control groups with no exercise than when using control groups with exercise. No significant improvement was found in executive function.

CONCLUSION

Regular rhythmic movement likely improves physical function, global cognitive function, and QOL in healthy older adults. The effect of rhythmic movement on the physical function in older adults is similar to that of routine exercise. Further studies on cognitive function of healthy older adults using larger samples of populations with more balanced sex ratios with long-term follow-up are particularly encouraged.

Home-Based Health Care Interventions for People Aged 75 Years and Above With Chronic, Noninflammatory Musculoskeletal Pain: A Scoping Review

BACKGROUND AND PURPOSE

Chronic, noninflammatory musculoskeletal pain is common in the aged population and management can be challenging for older people due to multimorbidity, social isolation, and physical frailty. The aim of this scoping review is to summarize and discuss the evidence related to home-based health care interventions for older adults, with chronic, musculoskeletal pain.

METHODS

A review of the literature using 8 electronic databases (Embase, MEDLINE, CINAHL, PubMed, Cochrane Library, Physiotherapy Evidence Database [PEDro], Scopus, and Web of Science) was performed, following the PRISMA-ScR guidelines. English language published studies that assessed home-based health care intervention/s, in men and women 75 years and older, with chronic, noninflammatory musculoskeletal pain where included. Two authors independently reviewed the articles and extracted data into a preformulated chart.

RESULTS AND DISCUSSION

The database search identified 4722 studies of which 7 studies met the inclusion criteria. Six of the 7 studies were randomized controlled trials and 5 studies focused on a single-site pain. The type of home-based interventions in the included studies was physical therapy (n = 2), psychotherapy (n = 3), and multimodal therapy (combination of multiple therapies) (n = 2). Participation completion rate was more than 74% in 6 out of 7 studies. Most studies used pain and/or physical function as their primary outcome (n = 6). Music therapy showed a statistically significant reduction in visual analog scale score for pain, and there was a trend toward improvement of pain and function in the physical therapy studies. No significant differences in outcomes between intervention and control groups were observed in the multimodal studies.

CONCLUSION

This review highlights the scarcity of evidence related to home-based health interventions in older people 75 years and older, living with chronic, noninflammatory musculoskeletal pain. The findings were that physical, psychotherapeutic, and multimodal interventions are usually well tolerated and can be delivered as a safe self-management option. There remains a substantial need for more high-quality research with wider range of home-based interventions and comprehensive assessment of outcomes for this age group.

Exercise & Sports Science Australia (ESSA) updated Position Statement on exercise and physical activity for people with hip/knee osteoarthritis

This Position Statement is an update to the existing statement. It is intended for all health practitioners who manage people with hip/knee osteoarthritis. It synthesises the most recent evidence (with a focus on clinical guidelines and systematic reviews) for exercise in people with hip/knee osteoarthritis, and provides guidance to practitioners about how best to implement exercise in clinical practice. Clinical practice guidelines for hip/knee osteoarthritis advocate physical activity and exercise as fundamental core components of evidence-based management. Research evidence indicates that exercise can reduce joint pain, increase physical function, and improve quality of life in hip/knee osteoarthritis, and that a range of exercise types (both supervised and unsupervised) may be beneficial. Exercise dosage should be guided by the principles of the American College of Sports Medicine. As people with osteoarthritis experience many barriers to exercise, practitioners should take an active role in monitoring and promoting adherence to exercise in order to optimise therapeutic benefits.

Behavior Change Techniques Improve Adherence to Physical Activity Recommendations for Adults with Metabolic Syndrome: A Systematic Review

BACKGROUND

Exercise and physical activity interventions improve short-term outcomes for people with metabolic syndrome, but long-term improvements are reliant on sustained adherence to lifestyle change for effective management of the syndrome. Effective ways of improving adherence to physical activity and exercise recommendations in this population are unknown. This systematic review aims to determine which interventions enhance adherence to physical activity and/or exercise recommendations for people with metabolic syndrome.

METHODS

Electronic databases MEDLINE, PubMed, CINAHL, SPORTdiscuss and ProQuest were searched to July 2022. Risk of bias was assessed using the Cochrane risk of bias tool and overall certainty of evidence assessed using the Grading of Recommendation Assessment, Development and Evaluation approach.

RESULTS

Four randomized controlled trials with 428 participants (mean age 49-61 years) were included. There was very low certainty evidence from two trials that goal setting interventions may improve adherence to physical activity recommendations over three to six months. There was low certainty evidence from two trials that self-monitoring and feedback interventions increased adherence to physical activity interventions over 12 months for people with metabolic syndrome.

CONCLUSION

Clinicians and researchers may consider using behavior change strategies such as goal setting, monitoring and feedback in interventions for people with metabolic syndrome to increase adherence to physical activity and exercise recommendations over 3 to 12 months, but high-quality evidence is lacking.

Effect of compression by elastic bandages on pain and function in individuals with knee osteoarthritis: protocol of a randomised controlled clinical trial

INTRODUCTION

Although compression is used to control pain in knee osteoarthritis (KOA), its clinical application is poorly supported, and there is a lack of scientific evidence to support its clinical use. As a low-cost and accessible protocol, compression using elastic bands could be a non-pharmacological intervention to reduce pain and improve physical function in individuals with KOA. This study aims to evaluate the effects of compression on pain and function in individuals with KOA.

METHODS AND ANALYSIS

A randomised controlled clinical trial will be conducted. Individuals with KOA (n=90; both sexes; between 40 and 75 years old) will be allocated to three groups (n=30/group): compression (compression by the elastic bandage on the affected knee, once a day for 20 min, on four consecutive days); sham (same protocol, but the elastic band is placed around the affected knee without compression) and control (no intervention). The individuals in the three groups will be evaluated 1 day before the first intervention, 1 day after the last intervention, and at the 12th and 24th weeks after the end of the intervention. Pain intensity by the Visual Analogue Scale and pain scale from Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) will be the primary outcomes. The secondary variables will be physical function assessed by the WOMAC questionnaire and physical tests (step test; 30 s sit and stand test; 40 m accelerated walk test). The Global Rating of Change Scale (GRC) will also be applied to quantify the volunteers' perceived change.

ETHICS AND DISSEMINATION

The project was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (3955692). The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04724902.

Digital Rehabilitation Programs Improve Therapeutic Exercise Adherence for Patients With Musculoskeletal Conditions: A Systematic Review With Meta-Analysis

OBJECTIVE: To investigate the effects of digital rehabilitation for improving adherence to therapeutic exercise in people with musculoskeletal conditions. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: Five databases were searched from their inception to March 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials evaluating digital rehabilitation programs to improve adherence to therapeutic exercise for people with musculoskeletal conditions. DATA SYNTHESIS: We calculated standardized mean differences (SMDs) or mean differences (MDs) and 95% confidence intervals (CIs). Certainty of evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Bias was assessed using the Cochrane risk of bias tool. RESULTS: Eleven trials were included in the meta-analysis (n = 1144 participants). At short-term follow-up, digital rehabilitation was no better than nondigital rehabilitation (3 trials, adherence rate of prescribed exercise test SMD 0.50, 95% CI: -0.13, 1.13; 2 trials, self-reported exercise adherence test MD 1.07, 95% CI: 0.58, 1.56; 2 trials, assessor-reported exercise adherence test SMD -0.10, 95% CI: -0.56, 0.36). At intermediate-term follow-up, digital rehabilitation improved exercise adherence compared with nondigital rehabilitation (6 trials, adherence rate of prescribed exercise test SMD 0.53, 95% CI: 0.35, 0.70; 2 trials, self-reported exercise adherence test MD 1.50, 95% CI: 0.76, 2.25; 2 trials, Exercise Adherence Rating Scale test MD 5.86, 95% CI: 0.08, 11.65). At long-term follow-up, there was no clinically important difference between digital and nondigital rehabilitation (2 trials, adherence rate of prescribed exercise test SMD 0.28, 95% CI: -0.14, 0.70; 1 trial, self-reported exercise adherence test MD 0.20, 95% CI: -0.91, 1.31). CONCLUSION: Digital rehabilitation was effective at improving therapeutic exercise adherence in musculoskeletal conditions at mid-term follow-up, but not at short- and long-term follow-up. J Orthop Sports Phys Ther 2022;52(11):726-739. Epub: 12 August 2022. doi:10.2519/jospt.2022.11384.

Treatment Adherence in CKD and Support From Health care Providers: A Qualitative Study

Rationale & Objective

Adherence to recommended medical treatment is critical in chronic kidney disease (CKD) to prevent complications and progression to kidney failure. Overall adherence to treatment is low in CKD, and as few as 40% of patients with kidney failure receive any documented CKD-related care. The purpose of this study was to explore the experiences of patients with CKD and their adherence to CKD treatment plans, and the role their health care providers played in supporting their adherence.

Study Design

One-on-one interviews were conducted in 2019-2020 using a semi-structured interview guide. Participants described experiences with adherence to treatment plans and what they did when experiencing difficulty.

Setting & Participants

Participants were recruited from the Chronic Renal Insufficiency Cohort (CRIC) study. All CRIC participants were older than 21 years with CKD stages 2-4; this sample consisted of participants from the University of Pennsylvania CRIC site.

Analytical Approach

Interviews were recorded, transcribed, and coded using conventional content analysis. Data were organized into themes using NVivo 12.

Results

The sample (n = 32) had a mean age of 67 years, 53% were women, 59% were non-White, with a mean estimated glomerular filtration rate of 56.6 mL/min/1.73 m2. From analysis of factors relevant to treatment planning and adherence, following 4 major themes emerged: patient factors (multiple chronic conditions, motivation, outlook), provider factors (attentiveness, availability/accessibility, communication), treatment planning factors (lack of plan, proactive research, provider-focused treatment goals, and shared decision making), and treatment plan responses (disagreeing with treatment, perceived capability deficit, lack of information, and positive feedback).

Limitations

The sample was drawn from the CRIC study, which may not be representative of the general population with CKD.

Conclusions

These themes align with Behavioral Learning Theory, which includes concepts of internal antecedents (patient factors), external antecedents (provider factors), behavior (treatment planning factors), and consequences (treatment plan responses). In particular, the treatment plan responses point to innovative potential intervention approaches to support treatment adherence in CKD.

Factors impacting adherence to an exercise-based physical therapy program for individuals with low back pain

Background/Objective

Exercise-based rehabilitation is a conservative management approach for individuals with low back pain. However, adherence rates for conservative management are often low and the reasons for this are not well described. The objective of this study was to evaluate predictors of adherence and patient-reported reasons for non-adherence after ceasing a supervised exercise-based rehabilitation program in individuals with low back pain.

Design

Retrospective observational study.

Methods

Data was retrospectively analyzed from 5 rehabilitation clinics utilizing a standardized exercise-based rehabilitation program. Baseline demographics, diagnosis and symptom specific features, visit number, and discontinuation profiles were quantified for 2,243 patients who underwent the program.

Results

Forty-three percent (43%) of participants were adherent to the program, with the majority (31.7%) discontinuing treatment prior to completion due to logistic and accessibility issues. Another 13.2% discontinued prior to the prescribed duration due to clinically significant improvements in pain and/or disability without formal discharge evaluation, whereas 8.3% did not continue due to lack of improvement. Finally, 6.0% were discharged for related and unrelated medical reasons including surgery. Individuals diagnosed with disc pathology were most likely to be adherent to the program.

Limitations

This study was a retrospective chart review with missing data for some variables. Future studies with a prospective design would increase quality of evidence.

Conclusions

The majority of individuals prescribed an in-clinic exercise-based rehabilitation program are non-adherent. Patient diagnosis was the most important predictor of adherence. For those who were not adherent, important barriers include personal issues, insufficient insurance authorization and lack of geographic accessibility.

Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study

BACKGROUND

Comorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.

OBJECTIVE

The aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.

METHODS

Ad hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis.

RESULTS

From a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from -16.82, 95% CI -20.32 to -13.42 in cluster 1 to -20.10, 95% CI -32.64 to -7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).

CONCLUSIONS

A multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

The impact of breast cancer on fears of exercise and exercise identity

OBJECTIVES

Low exercise adherence is common amongst breast cancer (BC) patients. This study aimed to understand BC patients exercise identity and fears of exercise to identify barriers to exercise participation.

METHODS

Women (18 years plus) currently undergoing, or completed (in remission), chemotherapy for BC, and women (18 years plus) with no cancer history completed three validated questionnaires: Exercise Identity Scale (EI), Exercise Fear Avoidance Scale (EFAS) and Fear of Physical Activity/Exercise Scale - Breast Cancer.

RESULTS

86 women were included (BC: n = 51 - non-cancer: n = 35). There were no significant differences between groups when comparing overall EI (p = 0.240; d=0.127) and EFAS (p = 0.060; d=0.203) scores. BC reported significantly higher scores on specific questions related to fear during exercise (EFAS 2,3, and 5; p = <0.005). Associations were observed between EI and EFAS questionnaire scores in BC (r = -0.342; p = 0.014), and EI scores and exercise levels in both groups (BC, r = 0.527; p = <0.001; non-cancer, r = 0.639; p = <0.001).

CONCLUSION

Results suggest women with BC may have specific concerns and fears of exercise compared to age-matched controls. Education may mitigate fears, increase exercise identity, and promote exercise uptake.

PRACTICAL IMPLICATIONS

Education provided by clinicians at BC diagnosis regarding the benefits and safety of exercise may help mitigate fear and promote exercise identity.

Patients' and clinicians' experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

BACKGROUND

We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups ('high muscle strength subgroup', 'low muscle strength subgroup', 'obesity subgroup'), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the 'obesity subgroup'). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements.

METHODS

Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed.

RESULTS

We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the 'obesity subgroup'. In this 'obesity subgroup', physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the 'high muscle strength subgroup', the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these.

CONCLUSION

Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the 'obesity subgroup'. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy.

TRIAL REGISTRATION

The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).